HospitalInspections.org

Based on observation and interview, the facility failed to post the Emergency Medical Treatment and women in labor signage in the ambulance entrance to the emergency room. This could result in patients not being informed of their rights under EMTALA that arrive via ambulance to the emergency room.

Findings include:

An observation of the facility's ambulance entrance, on the morning of 12.19.22, revealed there was no EMTALA signage located on the outside or inside of the building at the entrance to the emergency room.

During an interview on the morning of 12.19.2022, in the facility's ambulance entrance, Staff #3, CNO and Staff #1 CEO who were present during the tour were asked by the surveyor if the signage was visible to them in the entrance and they both responded in part, "We do not see any signage located at this entrance." Staff #1 CEO and Staff #3 CNO verified that the signage was not present at the ambulance entrance either outside the building or on the inside of the building near the ambulance entrance.

Based on interview, and record reviews, the hospital did not follow their transfer policy to ensure required information had been completed in their Memorandum of Transfer (MOT) forms, in that, the physician's certification which includes a summary of the risks and benefits, required by paragraph (6)(B)(ii) of this subsection, was not documented in the MOT's, for 4 of 4 patients (Patients #12, #14, #15 & #16), who had been transferred out of this hospital in the last 60 days.

Findings included:

Review of the hospital's MOT forms, and other attached forms, for 4 of 4 patients (Patients #12, #14, #15 & #16), who had transferred out of the hospital in the last 60 days revealed the following:

Patient #12: This patient was transferred out of the hospital on 11.5.2022. His MOT did not document a summary of the patient's risks and benefits of a transfer. There was no other attached form with this information. The physician's certification of the patient's risks and benefits of a transfer, was a signed statement that read, "based on these reasonable risks and benefits...," but did not include what these reasonable risks and benefits were.

Patient #14: This patient was transferred out of the hospital on 11.5.2022. His MOT did not document a summary of the patient's risks and benefits of a transfer. There was no other attached form with this information. The physician's certification of the patient's risks and benefits of a transfer, was a signed statement that read, "based on these reasonable risks and benefits...," but did not include what these reasonable risks and benefits were.

Patient #15: This patient was transferred out of the hospital on 11.6.2022. His MOT did not document a summary of the patient's risks and benefits of a transfer. There was no other attached form with this information. The physician's certification of the patient's risks and benefits of a transfer, was a signed statement that read, "based on these reasonable risks and benefits...," but did not include what these reasonable risks and benefits were.

Patient #16: This patient was transferred out of the hospital on 11.6.2022. His MOT did not document a summary of the patient's risks and benefits of a transfer. There was no other attached form with this information. The physician's certification of the patient's risks and benefits of a transfer, was a signed statement that read, "based on these reasonable risks and benefits...," but did not include what these reasonable risks and benefits were.

Review of the hospital's Policy #: 9500-LD-1024 " Transfer of Patients to Another Facility" policy, effective date of 12.2015 stated in part,

"2. A physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risk to the patient and, in the case of labor, to the unborn child from effecting the transfer."

In an interview at 3:30 pm on 12.19.2022 with the Staff #3 who is the Chief Nursing Officer, verified that the physician's summary of the risks and benefits of transfer had not been documented in the hospital's Memorandum of Transfer forms in 4 of 4 MOTs reviewed, as required by hospital policy and regulation as she was present at the time of the record reviews and when asked by the surveyor why the MOT was incomplete she stated in part, "I can see this is a problem and do not have an answer as to why these are not complete."